Provider First Line Business Practice Location Address:
543 FREDERICK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA CRUZ
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95062-2635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-458-1940
Provider Business Practice Location Address Fax Number:
831-458-1940
Provider Enumeration Date:
02/14/2023